99214: Established Patient Visit, Level 4

Transcription

1 New problem, with prescription drug management; or Undiagnosed new problem with uncertain outcome; or Major elective surgery in a patient without identified risk factors; or Acute illness with systemic symptoms; or Physiological tests under stress; or Diagnostic endoscopies; CV imaging studies with contrast in patient with no identified risk factor. All visits require a chief complaint/reason for visit/presenting problem. Chief Complaint: Headache The patient presents today for follow up of her hypothyroidism. She also notes that over the last several months she has had unilateral throbbing headaches, focused over her right eye. She states she is very light sensitive to them and is somewhat sick to her stomach. She denies a relationship with her menstrual cycle, which she states is regular. She denies other associated neurological complaints. She also notes her allergies have been worsening in the last several days. She has been using Claritin and Sudafed but she still has a lot of runny, sinus discharge. She denies fever or chills. Her family history is negative for migraines. He does not smoke or use alcohol. Medicines: Synthroid daily, Claritin, 10 mg q.d. I started her on Flonase nasal spray today and also Imitrex 25 mg prn. She appears well. Weight 148 pounds, BP 110/70, Pulse 76 and regular. HEENT: Normocephalic/ atraumatic, non tender. TM s are normal bilaterally. PERRLA. Funduscopic examination shows sharp discs. Oropharnyx is negative. Neck: No adenopathy or thyromegaly. Lungs: Clear to A/P Heart: RRR, Normal S1, S2 Neurological: Alert and oriented. Normal gait. 2+ DTR s throughout. Normal coordination. Assessment and Plan: 1. Hypothyroidism: she appears euthryoid. Continue Synthroid mg a day. 2. Allergic rhinitis. I will add Flonase nasal spray to her regimen. 3. Migraine headaches. I will try Imitrex 25 mg at the onset of headache and she will repeat in two hours if needed. 4. Return prn. 4 elements (or status of 3 chronic diseases) location duration quality associated sign/symptom 2-9 elements GU Neuro Allergies Constitutional General appearance Vital signs TM s Pupils Optic Discs Oropharnyx Neck Neck Lymph All documented Exam 12 bullets (1997) MDM Lungs - auscultation Lungs - percussion Heart auscultation Psych oriented Psych - mood MS gait DTR s New problem with prescription drug management Page 1 of 7 All rights reserved Betsy Nicoletti

2 New problem, with prescription drug management; or Undiagnosed new problem with uncertain outcome; or Major elective surgery in a patient without identified risk factors; or Acute illness with systemic symptoms; or Physiological tests under stress; or Diagnostic endoscopies; CV imaging studies with contrast in patient with no identified risk factor. All visits require a chief complaint/reason for visit/presenting problem. SUBJECTIVE: Patient presents today for a four-month follow-up of diabetes, hypertension, COPD. She has been doing pretty well recently. As far as type 2 diabetes, it is pretty well controlled. Hemoglobin A1C is 6.3 today. She denies any polyuria, polydipsia, or polyphagia. Actually had some hypoglycemic symptoms at night she decreased her glipizide to just one pill at night instead of two. As far as COPD, it has been pretty well controlled. She is on Advair now. She seems to be breathing a little bit better. She went through pulmonary rehab as well and sees pulmonology on a regular basis. GERD is well controlled with cimetidine. Her pain seems well controlled at the Pain Clinic. She sees them on a regular basis. She had no other complaints or concerns today. MEDICATIONS: 1. Verapamil 240 mg daily 2. Glyburide 5 mg two in the morning and one in the evening 3. Lasix 40 mg daily 4. Actos 30 mg daily 2-9 elements 5. Percocet as needed 6. Albuterol MDI as needed Constitutional 7. Cimetidine 800 mg at nighttime CV 8. DuoNeb as needed Respiratory 9. Advair 250/50 twice daily GI Endo SOCIAL HISTORY: Ex-smoker, no alcohol use. She is divorced and has a significant other now. Disabled. REVIEW OF SYSTEMS: Denies any fever or chills, no chest pain, shortness of breath or leg edema. 4 elements (or status of 3 chronic diseases) Past medical Social history Status of 3 chronic problems (CONTINUED) Page 2 of 7 All rights reserved Betsy Nicoletti

3 OBJECTIVE: Blood pressure 132/62. Pulse 72. Resp.20. In general, alert and oriented, morbidly obese, middle-aged, white female in no acute distress, in a wheelchair. She had nasal oxygen and appeared comfortable. Oral mucosa moist and pink, no lesions. Neck supple, no JVD. Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Cardiovascular: distant heart sounds. Abdomen: morbidly obese. Extremities have no edema, normal sensation to monofilament exam, no diabetic ulcers. Const: 3 vital signs Psych: mood & affect ENT: lips, teeth & gums Resp AUSC GI masses Neuro - sensation Exam 12 bullets (1997) General appearance Respiratory effort Neck CV AUSC CV Edema Skin inspection ASSESSMENT AND PLAN: 1. Type 2 diabetes, well controlled. Continue Actos mg daily and continue with glipizide 5 mg two in the morning and one at night. Will check hemoglobin A1C in another few months. 2. COPD, stable. Continue Advair, oxygen, and inhalers as needed. Follow up with pulmonology as scheduled. 3. CHF, stable. Continue Lasix 40 mg daily. 4. Hypertension, well controlled. Continue Verapamil 240 mg daily. 5. GERD, stable. Continue cimetidine 800 mg at nighttime. 6. Chronic pain. Follow up with Pain Clinic. 7. Healthcare maintenance. I will see her for a physical exam, as she is overdue for that. At next visit we will get lab tests prior to that exam. MDM Moderate 3 or more chronic problems with prescription drug management Page 3 of 7 All rights reserved Betsy Nicoletti

4 New problem, with prescription drug management; or Undiagnosed new problem with uncertain outcome; or Major elective surgery in a patient without identified risk factors; or Acute illness with systemic symptoms; or Physiological tests under stress; or Diagnostic endoscopies; CV imaging studies with contrast in patient with no identified risk factor. All visits require a chief complaint/reason for visit/presenting problem. Dear David: I had the opportunity to follow up with patient. I had last seen her six months ago for atrial fibrillation and valvular lesions. Since her last visit, she has been feeling reasonably well. She does describe increased lower extremity swelling. She informs me her hydrochlorothiazide was switched to Lasix with good results. She has been using compression stockings and has been trying to watch her diet for the sodium content by avoiding certain foods at the manor. 4 elements (or status of 3 chronic diseases) location modifying factor severity associated signs & symptoms She is not extremely active citing the nursing staff limiting her activities secondary to fear of her falling. She however denies any symptoms of chest pain. Denies any recent shortness of breath exacerbations. Denies any symptoms of orthopnea or paroxysmal nocturnal dyspnea. She is asymptomatic towards her atrial fibrillation and denies any symptoms of palpitations, syncope, or new syncope. CV Resp 2-9 elements EKG shows atrial fibrillation with mild irregularity and a controlled ventricular rate. Mild nonspecific ST abnormalities. There is significant baseline artifact. No change compared to EKG from March Current Medications: 1. Atenolol 100 mg q.d. 2. Aspirin 81 mg q.d. 3. Coumadin adjusted to INR. 4. Lisinopril 2.5 mg q.d. 5. Digoxin mg q.d. 6. Lasix 80 mg q.d. 7. Levothyroxine. 8. Folic acid. Past medical (CONTINUED) Page 4 of 7 All rights reserved Betsy Nicoletti

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age 5 of 7 All rights reserved Betsy Nicoletti

6 New problem, with prescription drug management; or Undiagnosed new problem with uncertain outcome; or Major elective surgery in a patient without identified risk factors; or Acute illness with systemic symptoms; or Physiological tests under stress; or Diagnostic endoscopies; CV imaging studies with contrast in patient with no identified risk factor. CHIEF COMPLAINT: Bumps around her anus. : This is an established patient. Patient reports about a year to a year a half she has had several small bumps near her anus. They are slightly itchy and irritating. Sometimes when she wipes she ll get a little bit of blood, or some drainage from them, otherwise she really has no other problem with them. She denies ever having a perirectal abscess before or perianal abscess. Denies ever having a pilonidal cyst in the past. She has never had a problem with hemorrhoids in the past. She has no problem with constipation or diarrhea and no other complaints associated with these. She does not think she has any drainage. She usually wears a throng and has not noticed any soilage on her pants. She has had some warts removed from her vulva in the past and doesn t seem to think this is the same. PAST HISTORY: Significant for some depression. SURGICAL HISTORY: C-section in A NovaSure procedure in Tonsils and adenoids as a child. MEDICATIONS: Current medications include Cymbalta 60mg. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is married and has two children. She smokes approximately a pack of cigarettes per day. She does not drink any alcohol. She works as a rehab aide locally. FAMILY HISTORY: Significant for heart disease and her father had adrenal cancer. Also significant for depression. : PSYCHE: Significant for the above mentioned depression. RESPIRATORY: No chronic cough or sputum production. CARDIOVASCULAR: No chest pain or heart palpitations. GI: As per MSK: Normal 4 required location quality associated signs and symptoms duration GI resp CV MS psyche 2-9 required All three documented (CONTINUED) Page 6 of 7 All rights reserved Betsy Nicoletti

7 PHYSICAL EXAM: Exam reveals an awake and alert female who appears her stated age and appears in good shape- normal mood and affect. Height 5 3 Weight 145lbs. BP 140/72 LUNG: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. No HSM, no hernia. RECTAL: Her anal region shows at the midline in the cleft region going posterior as she as on her side, we ll call that 12 o clock, there is a small dimple right there. It could easily be a chronic fistula tract from a previous perirectal abscess if she had had one. There does not appear to be any drainage at this time. Just off the side there are two other small cyst-like areas. They are 2-3 mm in size. They almost appear like infected inclusion cysts. They have small amount of drainage if I put pressure on them. Of note, there is absolutely no hair present in this area and on further questioning of the patient, she does keep the area completely shaved on a regular basis. Rectal examination revealed normal tone and no significant abnormalities or masses felt. No signs of an abscess or scarring were felt. Upon applying pressure behind the area, there appeared to be a fistula over these two cyst areas. There was no increased drainage. There are also several small wart-like lesions present on the perineum between the posterior wall of the vagina and the rectum. Otherwise, the rest of the exam is unremarkable. There are no signs of pruritus, inflammation, or irritation and no erythema. Rectal mucosa appeared to be quite normal. Occult negative. Skin: warm. Negative lymph nodes in groin. EXAM 12 bullets from 1997 multi-system exam Vital signs General appearance Resp auscultation CV auscultation GI masses GI no organs GI hernia GI occult test GI anus and perineum Lymph groin Skin palpitation Psych mood and affect ASSESSMENT: Chronic fistula versus several small chronic draining cysts versus ingrown hair plus several small warts. PLAN: I recommend we go to the OR and do an exam under anesthesia. That way I can easily use a standard probe to find out if the posterior 12 o clock lesion is in fact a chronic fistula tract. The other two lesions can also be probed and if they are truly just draining cysts, they can be ID d and formally debrided extensively which would be quite helpful in the healing process. She is quite happy with this and we ll be performing this soon. The risks, benefits, and complications have been discussed in great detail. Consent has been signed. MDM New problem to examiner. Risk: undiagnosed new presenting problem Page 7 of 7 All rights reserved Betsy Nicoletti